A patient is admitted intubated and ventilated with massive haemoptysis.
a) List the investigations that will assist with localizing the site of bleeding. Include the advantages and limitations of each investigation in your answer. (50% marks)
b) A single active bleeding site is found to originate from the left lung. Discuss the specific management options for the bleeding. (50% marks)
The role of rigid bronchoscopy was not listed as an option in many candidates' answers, and there was also a lack of consideration for the different sided DLTs for several candidates. The clinical scenario presented was urgent and many candidates listed investigations which would have led to patient detriment e.g. MRI. Many candidates answered part b) with the management of coagulopathy when specific management of an isolated bleeding site was required. Clinical management and the answers in the part 2 CICM exam often require context, and this is no different in the vivas and clinical cases, and there are further comments to demonstrate this later in the report.
Quite right, to send the patient choking on blood into the MRI scanner should be viewed as a huge blunder of airway etiquette, and would have led to some low marks in this SAQ. Some may consider this as a critical failure point, i.e. where the answer is dangerous in some fundamental way, and should not pass even though the rest of the points mentioned are technically valid.
a) Investigations:
Investigation | Advantages | Disadvantages |
CXR | Ubiquitous, easily available Already necessary for intubated patients Also confirms ETT position Minimal radiation exposure |
Poor accuracy Cannot localise source of bleeding beyond lobes |
Non-contrast CT | Can reveal the causal pathology (eg. abscess) Can localise the bleeding site (eg. area of ground glass) No contrast exposure |
May not identify bleeding vessels Risk of transport |
CT angiogram | Highly accurate for localising the site of bronchial arterial bleeding |
Risk of transport May not identify endobronchial lesions in the presence of clot Bleeding rate would have to be considerable to be able to visualise extravasation |
Digital subtraction angiography | Able to perform embolisation in the same procedure May define the feeding vessels of an AVM or tumour |
Large contrast and radiation exposure On its own, may not be able to find the lesion (i.e. best when combined with CTA) |
Fiberoptic bronchoscopy | Able to localise the source of bleeding when it is endobronchial Offers various endoluminal management options Able to clear the airway |
Blood may obscure the view Clots may be too large to suction May not be able to identify a very distal lesion, or define an extrabronchial pathology May cause more bleeding |
b) Management options:
1) Achieve lung isolation
2) Trial conservative management:
3) Interventional bronchoscopy techniques
4) Rigid bronchoscopy techniques
5) Interventional radiology
6) Surgery is the last option:
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